Report
T h e Hasti n g s C e n ter
FROM THE EDITOR
VOLUME 44, NO. 5 • SEPTEMBER-OCTOBER 2014
Learning about Teaching
T
here are three broad themes in this issue of the Hastings Center Report. First, a special report published as a supplement to the issue addresses the medical and health policy issues faced by lesbian, gay, bisexual, and transgender patients. The special report was both proposed to us and guest edited by Tia Powell, a clinical ethicist at Montefiore Medical Center, and Mary Beth Foglia, a clinical ethicist with Veterans Affairs. In an introduction to the report, Powell and Foglia call for greater and better engagement in bioethics with LGBT issues, and the set of essays they have assembled follows up their call by exploring, among other things, the role of medicine in gender identity, the complexities of addressing gender dysphoria in children, constraints on conducting research on lesbian and gay youth, problems in the physician-patient relationship for lesbian and gay patients, and both the importance of trying to elicit information about a patient’s sexual orientation and the difficulty. Inside the issue, the two articles take up questions about how caregivers may justify a refusal to provide a medical service that a patient has requested. In the lead article, Mark Wicclair and Douglas B. White consider a physician’s refusal to provide a service on grounds that it poses an unacceptable ratio of risks to benefits. Surgeons are usually given considerably more discretion than other physicians to make such decisions. Intensivists, for example, often end up acceding to patients’ families’ requests when making decisions about life-prolonging treatments. Wicclair and White argue that this disparity does not make sense, and they propose that procedures be put in place to resolve disputes between surgeons and their patients, limiting surgeons’ discretion. In the second article, Daniel Brudney turns to refusals that are often justified by appeal to a caregiver’s right of conscience—a right, that is, not to have to provide a service that conflicts with the caregiver’s values—and he examines an alternative justification for some of those decisions. Instead of appealing to a right of conscience, caregivers sometimes base a refusal on a claim about the goals of medical practice. For example, a physician might refuse to provide an abortion on grounds that terminating a pregnancy (if the pregnancy does not itself pose a health risk to the mother) is simply outside the scope of medicine; pregnancy is not a thing needing treatment. Brudney’s aim is not to offer a definitive evaluation of these positions, but to figure out what the ground rules are for evaluating them. The issue also contains a set of essays that have emerged from a collaborative effort by The Hastings Center and Presidential Commission for the Study of Bioethical Issues to promote scholarly engagement with the practical problem of teaching caregivers, researchers, scientists, and others to address bioethical problems. One year ago, in the September-October issue of the Report, Millie Solomon, president of The Hastings Center, and Lisa Lee, executive director of the PCSBI, issued a call for papers on this topic. By the time of the March deadline, we had received eighty-four submissions. Readers at the commission and the Center selected twenty-nine of these for further consideration, and a team of outside reviewers (Joseph J. Fins, Alan Fleischman, Jeffrey Kahn, Tomi Kushner, Paul Lombardo, Alex London, Robert Pearlman, Sean Philpott, Jennifer Ruger, and Wayne Shelton) then helped us narrow that group to a final set. Still, we have ended up with more than we can assemble in a single batch. What appears here is, rather, the first installment of a series that will appear in the pages of the Report well into the 2015 volume. —GEKn 2 HASTIN G S C E N T E R R E P ORT
Gregory E. Kaebnick Editor Laura Haupt Managing Editor Susan Gilbert Stephen R. Latham Contributing Editors Nora Porter Art Director Nancy Berlinger Michael K. Gusmano Josephine Johnston Erik Parens Editorial Committee The Hastings Center Report (ISSN 0093-0334 print; ISSN 1552-146X online) is published bimonthly on behalf of The Hastings Center by Wiley Subscription Services, Inc., a Wiley Company, 111 River St., Hoboken, NJ 07030-5774. The Hastings Center, an independent, nonpartisan, nonprofit organization, addresses fundamental ethical issues in the areas of health, medicine, and the environment as they affect individuals, communities, and societies. For more information on the Center’s interdisciplinary research and education programs, visit its website at www.thehastingscenter.org. The Hastings Center Report is sent to individual and institutional subscribers. For ordering information, claims, and any inquiry concerning your journal subscription, please go to http:// www.wileycustomerhelp.com/ask or contact your nearest office. Americas: [email protected] or 1-800-8356770. Europe, Middle East, and Africa: [email protected]; +44 (0)-1865778315. Asia Pacific: cs-journals@wiley. com or +65-6511-8000. Periodicals postage paid at Hoboken, NJ, and additional mailing offices. postmaster: Send all address changes to the Hastings Center Report, Journal Customer Services, John Wiley and Sons, Inc., c/o The Sheridan Press, PO Box 465, Hanover, PA 17331. Contents copyright © 2014 by The Hastings Center. All rights reserved. September-October 2014
T h e Hasti n g s C e n ter
FROM THE EDITOR
VOLUME 44, NO. 5 • SEPTEMBER-OCTOBER 2014
Learning about Teaching
T
here are three broad themes in this issue of the Hastings Center Report. First, a special report published as a supplement to the issue addresses the medical and health policy issues faced by lesbian, gay, bisexual, and transgender patients. The special report was both proposed to us and guest edited by Tia Powell, a clinical ethicist at Montefiore Medical Center, and Mary Beth Foglia, a clinical ethicist with Veterans Affairs. In an introduction to the report, Powell and Foglia call for greater and better engagement in bioethics with LGBT issues, and the set of essays they have assembled follows up their call by exploring, among other things, the role of medicine in gender identity, the complexities of addressing gender dysphoria in children, constraints on conducting research on lesbian and gay youth, problems in the physician-patient relationship for lesbian and gay patients, and both the importance of trying to elicit information about a patient’s sexual orientation and the difficulty. Inside the issue, the two articles take up questions about how caregivers may justify a refusal to provide a medical service that a patient has requested. In the lead article, Mark Wicclair and Douglas B. White consider a physician’s refusal to provide a service on grounds that it poses an unacceptable ratio of risks to benefits. Surgeons are usually given considerably more discretion than other physicians to make such decisions. Intensivists, for example, often end up acceding to patients’ families’ requests when making decisions about life-prolonging treatments. Wicclair and White argue that this disparity does not make sense, and they propose that procedures be put in place to resolve disputes between surgeons and their patients, limiting surgeons’ discretion. In the second article, Daniel Brudney turns to refusals that are often justified by appeal to a caregiver’s right of conscience—a right, that is, not to have to provide a service that conflicts with the caregiver’s values—and he examines an alternative justification for some of those decisions. Instead of appealing to a right of conscience, caregivers sometimes base a refusal on a claim about the goals of medical practice. For example, a physician might refuse to provide an abortion on grounds that terminating a pregnancy (if the pregnancy does not itself pose a health risk to the mother) is simply outside the scope of medicine; pregnancy is not a thing needing treatment. Brudney’s aim is not to offer a definitive evaluation of these positions, but to figure out what the ground rules are for evaluating them. The issue also contains a set of essays that have emerged from a collaborative effort by The Hastings Center and Presidential Commission for the Study of Bioethical Issues to promote scholarly engagement with the practical problem of teaching caregivers, researchers, scientists, and others to address bioethical problems. One year ago, in the September-October issue of the Report, Millie Solomon, president of The Hastings Center, and Lisa Lee, executive director of the PCSBI, issued a call for papers on this topic. By the time of the March deadline, we had received eighty-four submissions. Readers at the commission and the Center selected twenty-nine of these for further consideration, and a team of outside reviewers (Joseph J. Fins, Alan Fleischman, Jeffrey Kahn, Tomi Kushner, Paul Lombardo, Alex London, Robert Pearlman, Sean Philpott, Jennifer Ruger, and Wayne Shelton) then helped us narrow that group to a final set. Still, we have ended up with more than we can assemble in a single batch. What appears here is, rather, the first installment of a series that will appear in the pages of the Report well into the 2015 volume. —GEKn 2 HASTIN G S C E N T E R R E P ORT
Gregory E. Kaebnick Editor Laura Haupt Managing Editor Susan Gilbert Stephen R. Latham Contributing Editors Nora Porter Art Director Nancy Berlinger Michael K. Gusmano Josephine Johnston Erik Parens Editorial Committee The Hastings Center Report (ISSN 0093-0334 print; ISSN 1552-146X online) is published bimonthly on behalf of The Hastings Center by Wiley Subscription Services, Inc., a Wiley Company, 111 River St., Hoboken, NJ 07030-5774. The Hastings Center, an independent, nonpartisan, nonprofit organization, addresses fundamental ethical issues in the areas of health, medicine, and the environment as they affect individuals, communities, and societies. For more information on the Center’s interdisciplinary research and education programs, visit its website at www.thehastingscenter.org. The Hastings Center Report is sent to individual and institutional subscribers. For ordering information, claims, and any inquiry concerning your journal subscription, please go to http:// www.wileycustomerhelp.com/ask or contact your nearest office. Americas: [email protected] or 1-800-8356770. Europe, Middle East, and Africa: [email protected]; +44 (0)-1865778315. Asia Pacific: cs-journals@wiley. com or +65-6511-8000. Periodicals postage paid at Hoboken, NJ, and additional mailing offices. postmaster: Send all address changes to the Hastings Center Report, Journal Customer Services, John Wiley and Sons, Inc., c/o The Sheridan Press, PO Box 465, Hanover, PA 17331. Contents copyright © 2014 by The Hastings Center. All rights reserved. September-October 2014
